Consideration of optimal isodose surface selection for target coverage in micro-multileaf collimator-based stereotactic radiotherapy for large cystic brain metastases: Comparison of 90%, 80% and 70% isodose surface-based planning

Objective: This study aims to compare dynamic conformal arc (DCA) plans based on different-percentage isodose surfaces (IDSs), normalised to 100% at the isocentre, for target coverage (TC; dose prescription) in stereotactic radiotherapy for large cystic brain metastases. Methods: The DCA plans were generated for 15 targets (5 spherical models and 10 metastatic brain lesions) based on 90%, 80% and 70% IDSs for dose prescription to attain ≥99% TC values using the Novalis Tx platform. These plans were optimised mainly by leaf margin and/or collimator angle adjustment, while similar arc arrangements were used. Results: TC values were equivalent among the three plans. Conformity index values were similar between the 80% and 70% plans, while they were worse in the 90% plans. Mean doses (D _mean) of the interior 3 mm rind structure were highest in the 70% plans, followed by the 80% plans and lowest in the 90% plans. D _mean of the exterior 3 mm rind structure and the ratio of 50%/100% isodose volumes (Paddick's gradient index values) were highest in the 90% plans, followed by 80% and lowest in the 70% plans. Conclusions: These results suggest that the 70% IDS plans might be beneficial for both tumour control and reducing toxicity to surrounding normal tissue if appropriate dose conformity and precise treatment set-up are ensured. The 90% IDS plans are unfavourable in view of inferior dose gradient outside the target and should be limited to cases in which the target dose homogeneity is given the highest priority.